Wisconsin Quality of Life Index for Adults Questionnaire (A-QLI)
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
It’s not complete instrument: please see source.
BACKGROUND INFORMATION (sample)
Sex‚ highest school grade‚ current marital status‚ racial/ethnic‚ religious affiliation‚ currently live with‚ current living arrangement‚ primary source of money‚
PHYSICAL HEALTH
The following questions refer to your health status. Please check (x) the most appropriate answer.
· In general‚ would you say your physical health is: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
· Compared to one year ago‚ how would you rate your health in general now? Much Worse‚ Somewhat Worse‚ About the Same‚ Somewhat Better‚ Much Better
Please choose the answer that best describes how true or false the following statements are for you.
· Compared to others my age. my health is as good as can be expected. Definitely False‚ Mostly False‚ Not Sure‚ Mostly True‚ Definitely True
· I expect my health to get worse. Definitely False‚ Mostly False‚ Not Sure‚ Mostly True‚ Definitely True
· Do you take medication for your health? ______Yes ______No
· If yes‚ how many different medications do you take? __________
(Include all medications; over the counter‚ prescribed‚ herbal‚ etc.)
· Do you require help in taking your medications correctly? ______Yes ______No
· Are you bothered by side effects from your medications? ______Yes ______No
During the past four weeks‚ have your activities been limited in any of the following ways due to problems with your physical health? Yes; completely‚ Yes; limited a lot‚ Yes; limited some‚ Yes; limited a little‚ No; not limited‚ Limited the kind
· Limited the kind could do? of activities you
· Limited the amount could do activities you would like to do?
· Limited you in performing self-care?
The following questions are about activities you might do on a typical day. In the past four weeks‚ has your health limited you in any of the following activities?
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Moderate Activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling or playing golf.
· Lifting or carrying groceries.
· Climbing several flights of stairs.
· Climbing one flight of stairs.
· Bending‚ kneeling or stooping.
· Walking several blocks.
· Walking one block.
· Walking short distances. (e.g. around your house)
SELF-CARE
These questions refer to self-care tasks. Please check (3) the most appropriate answer.
During the past four weeks…
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Did you need help from another person to take a bath or shower?
· Did you need help from another person to get dressed?
· Did you need help from another person to use the toilet?
· Did you need help from another person to eat?
· Did you need help from another person to get in or out of bed?
These questions refer to other important self-care tasks. Please check (3) the most appropriate answer.
During the past four weeks…
· Have you been able to go shopping for groceries without help?
· Have you been able to prepare your own meals without help?
· Have you been able to do your own housework without help?
· Have you been able to do your own laundry without help?
· Have you been able to use public transportation or drive your own car?
PAIN AND SYMPTOMS
· How much pain have you had during the past four weeks (check one)? Very Severe‚ Severe‚ Moderate‚ Mild‚ Very Mild‚ None
· During the past four weeks‚ how much has pain interfered with your normal activities? (check one): Not at all‚ Slightly‚ Moderately‚ Very much‚ Completely interferes
· Do you take pain medication? _____Yes _____No
· If yes: Is your pain controlled by the medication you take? Not at all‚ Some‚ Moderately‚ Quite a bit‚ Completely
· Do you use other measures to control your pain? _____Yes _____No
· If yes‚ what do you use?
· Overall‚ to what degree is your pain controlled? Not at all‚ Some‚ Moderately‚ Quite a bit‚ Completely
· Given the degree to which your pain is controlled‚ do you think something more should be done to help control your pain? _____Yes _____No
SOCIAL RELATIONS / SUPPORT
Very dissatisfied‚ Somewhat dissatisfied‚ Neither satisfied nor dissatisfied‚ Somewhat satisfied‚ Very satisfied
· How satisfied or dissatisfied are you with your relationships with family or friends? _____No family or friends
· How satisfied or dissatisfied are you with the amount of support you receive from family and friends?
· During the past four weeks‚ did you feel that your family or friends would be around if you needed assistance? Always‚ Often‚ Sometimes‚ Seldom‚ Never
· During the past four weeks‚ how often did you go to a religious activity (e.g. church‚ synagogue‚ etc.) or attend a community activity? _________________ (number of times)
· During the past four weeks‚ did your physical health limit your ability to socialize with family or friends? Always‚ Often‚ Sometimes‚ Seldom‚ Never
· During the past four weeks‚ did your emotional health limit your ability to socialize with family or friends? Always‚ Often‚ Sometimes‚ Seldom‚ Never
PSYCHOLOGICAL WELL-BEING
These questions are about how you have felt during the past four weeks. How much of the time. . .
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Did you feel full of pep?
· Have you been nervous?
· Did you feel down in the dumps?
· Have you felt peaceful and content?
· Did you feel your life had purpose?
· Have you felt hopeful about the future?
· Have you worried about dying?
· Did you feel life was worthwhile?
· Did you feel in control of your life?
· During the past four weeks‚ have you experienced a major loss? Yes‚ No
Please indicate below if during the past four weeks your activities have been limited in any of the following ways due to emotional difficulties.
Yes; completely limited‚ Yes; limited a lot‚ Yes; limited some‚ Yes; limited a little‚ No; not limited
· Limited the kind of activities you could do?
· Limited the amount of time you could do activities you would like to do?
· Limited you in performing self-care or attending social activities?
Now we’d like to ask you about some other areas of your life. To what extent are you experiencing difficulty in the area of:
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Managing day-to-day life (making decisions‚ handling money)?
· Getting enough sleep?
· Maintaining an adequate diet?
· Concentration‚ memory or confusion?
· Depression‚ hopelessness?
· Sexual activity?
· Mood swings?
· Drinking alcoholic beverages?
· Misusing drugs (including prescription drugs)?
OTHER ISSUES
Please choose the answer that best describes how true or false the following statements are for you.
Definitely False‚ Mostly False‚ Not Sure‚ Mostly True‚ Definitely True
· I spend time in activities that nourish my spiritual life.
· I am not interested in activities that nourish my spiritual life.
· I am satisfied with my spiritual life.
· I feel that I am treated with dignity and respect.
Very dissatisfied‚ Somewhat dissatisfied‚ Neither satisfied or dissatisfied‚ Somewhat satisfied‚ Very satisfied
· How satisfied or dissatisfied are you with your living arrangements?
· How satisfied or dissatisfied are you with the amount of privacy that you have?
· How satisfied or dissatisfied are you with the choices you have (e.g. control over time and your daily activities)?
· Please check the box below to indicate how you feel about your quality of life during the past four weeks. Lowest quality means things are as bad as they could be. Highest quality means things are the best they could be.
LOWEST QUALITY1 2 3 4 5 6 7 8 9 10 HIGHEST QUALITY
You have answered questions about areas of your health and quality of life. These areas are listed below. Please check (x) next to the three most important areas in which you would like to see improvement in your own life. Please read all areas before marking your selections.
· Physical Health _____
· Social Relations _____
· Pain _____
· Daily Activities _____
· Social Support _____
· Diet _____
· Spirituality _____
· Self-Care _____
· Your Feelings (mood/or mental health)_____
· Substance Use (drugs/alcohol)_____
PERSONAL GOALS
· Please list below the three most important personal goals that you have for improving your life.
· Goal 1: ___________________________
To what extent have you achieved this goal? Please check the box below to indicate the extent to which you have achieved this goal.
Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
· Goal 2: __________________________________
To what extent have you achieved this goal?
· ot at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
· Goal 3: ___________________________________
To what extent have you achieved this goal?
Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
This instrument can be found at: http://wqli.fmhi.usf.edu/wqli-instruments/
If you have any questions about this questionnaire‚ please call or write Marion Becker‚ Ph.D.‚ University of South Florida‚ Department of Community Mental Health‚ 13301 Bruce B. Downs Blvd.‚ MHC 1423‚ Tampa‚ Florida 33612-3899 Telephone: (813)974-7188 Fax: (813)974-6469 E-Mail: [email protected]